Association of neighbourhood food availability with the consumption of processed and ultra-processed food products by children in a city of Brazil: a multilevel analysis.

OBJECTIVE: To investigate the association between neighbourhood food availability and the consumption of ready-to-consume products (RCP), either processed or ultra-processed, and unprocessed/minimally processed foods (UF-MPF) by children. DESIGN: Cross-sectional. 24 h Dietary recalls were collected from children from January 2010 to June 2011. Neighbourhood food availability data were collected from 672 food stores located within 500 m of participants' homes, using an adapted and validated instrument. Neighbourhood-level socio-economic status (SES) was obtained by calculating the mean years of household head's education level in each census tract covered by 500 m buffers. Foods that were consumed by children and/or available in the food stores were classified based on their degree of industrial processing. Multilevel random-effect models examined the association between neighbourhood food availability and children's diets. SETTING: Santos, Brazil. SUBJECTS: Children (n 513) under 10 years old (292 aged <6 years, 221 aged ≥6 years). RESULTS: The availability of RCP in food stores was associated with increased RCP consumption (P<0·001) and decreased UF-MPF consumption (P<0·001). The consumption of UF-MPF was positively associated with neighbourhood-level SES (P<0·01), but not with the availability of UF-MPF in the neighbourhood. CONCLUSIONS: Results suggest that food policies and interventions that aim to reduce RCP consumption in Santos and similar settings should focus on reducing the availability in food stores. The results also suggest that interventions should not only increase the availability of UF-MPF in lower-SES neighbourhoods, but should strive to make UF-MPF accessible within these environments.

Development and Implementation: B'More Healthy Communities for Kid's Store and Wholesaler Intervention.

Higher rates of obesity and obesity-related chronic disease are prevalent in communities where there is limited access to affordable, healthy food. The B'More Healthy Communities for Kids (BHCK) trial worked at multiple levels of the food environment including food wholesalers and corner stores to improve the surrounding community's access to healthy food. The objective of this article is to describe the development and implementation of BHCK's corner store and wholesaler interventions through formal process evaluation. Researchers evaluated each level of the intervention to assess reach, dose delivered, and fidelity. Corner store and wholesaler reach, dose delivered, and fidelity were measured by number of interactions, promotional materials distributed, and maintenance of study materials, respectively. Overall, the corner store implementation showed moderate reach, dose delivered, and high fidelity. The wholesaler intervention was implemented with high reach, dose, and fidelity. The program held 355 corner store interactive sessions and had 9,347 community member interactions, 21% of which were with children between the ages of 10 and 14 years. There was a 15% increase in corner store promoted food stocking during Wave 1 and a 17% increase during Wave 2. These findings demonstrate a successfully implemented food retailer intervention in a low-income urban setting.

Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial.

OBJECTIVE: Small food store interventions show promise to increase healthy food access in under-resourced areas. However, none have tested the impact of price discounts on healthy food supply and demand. We tested the impact of store-directed price discounts and communications strategies, separately and combined, on the stocking, sales and prices of healthier foods and on storeowner psychosocial factors. DESIGN: Factorial design randomized controlled trial. SETTING: Twenty-four corner stores in low-income neighbourhoods of Baltimore City, MD, USA. SUBJECTS: Stores were randomized to pricing intervention, communications intervention, combined pricing and communications intervention, or control. Stores that received the pricing intervention were given a 10-30 % price discount by wholesalers on selected healthier food items during the 6-month trial. Communications stores received visual and interactive materials to promote healthy items, including signage, taste tests and refrigerators. RESULTS: All interventions showed significantly increased stock of promoted foods v. CONTROL: There was a significant treatment effect for daily unit sales of healthy snacks (ß=6·4, 95 % CI 0·9, 11·9) and prices of healthy staple foods (ß=-0·49, 95 % CI -0·90, -0·03) for the combined group v. control, but not for other intervention groups. There were no significant intervention effects on storeowner psychosocial factors. CONCLUSIONS: All interventions led to increased stock of healthier foods. The combined intervention was effective in increasing sales of healthier snacks, even though discounts on snacks were not passed to the consumer. Experimental research in small stores is needed to understand the mechanisms by which store-directed price promotions can increase healthy food supply and demand.

Barriers to and Facilitators of Stocking Healthy Food Options: Viewpoints of Baltimore City Small Storeowners.

Receptivity to strategies to improve the food environment by increasing access to healthier foods in small food stores is underexplored. We conducted 20 in-depth interviews with small storeowners of different ethnic backgrounds as part of a small-store intervention trial. Store owners perceived barriers and facilitators to purchase, stock, and promote healthy foods. Barriers mentioned included customer preferences for higher fat and sweeter taste and for lower prices; lower wholesaler availability of healthy food; and customers' lack of interest in health. Most store owners thought positively of taste tests, free samples, and communication interventions. However, they varied in terms of their expectations of the effect of these strategies on customers' healthy food purchases. The findings reported add to the limited data on motivating and working with small-store owners in low-income urban settings.

Healthy versus Unhealthy Suppliers in Food Desert Neighborhoods: A Network Analysis of Corner Stores' Food Supplier Networks.

BACKGROUND: Products in corner stores may be affected by the network of suppliers from which storeowners procure food and beverages. To date, this supplier network has not been well characterized. METHODS: Using network analysis, we examined the connections between corner stores (n = 24) in food deserts of Baltimore City (MD, USA) and their food/beverage suppliers (n = 42), to determine how different store and supplier characteristics correlated. RESULTS: Food and beverage suppliers fell into two categories: Those providing primarily healthy foods/beverages (n = 15) in the healthy supplier network (HSN) and those providing primarily unhealthy food/beverages (n = 41) in the unhealthy supplier network (UHSN). Corner store connections to suppliers in the UHSN were nearly two times greater (t = 5.23, p < 0.001), and key suppliers in the UHSN core were more diverse, compared to the HSN. The UHSN was significantly more cohesive and densely connected, with corner stores sharing a greater number of the same unhealthy suppliers, compared to HSN, which was less cohesive and sparsely connected (t = 5.82; p < 0.001). Compared to African Americans, Asian and Hispanic corner storeowners had on average -1.53 (p < 0.001) fewer connections to suppliers in the HSN (p < 0.001). CONCLUSIONS: Our findings indicate clear differences between corner stores' HSN and UHSN. Addressing ethnic/cultural differences of storeowners may also be important to consider.

B'More Healthy: Retail Rewards--design of a multi-level communications and pricing intervention to improve the food environment in Baltimore City.

BACKGROUND: Low-income black residents of Baltimore City have disproportionately higher rates of obesity and chronic disease than other Maryland residents. Increasing the availability and affordability of healthy food are key strategies to improve the food environment and can lead to healthier diets. This paper describes B'More Healthy: Retail Rewards (BHRR), an intervention that tests the effectiveness of performance-based pricing discounts and health communications, separately and combined, on healthy food purchasing and consumption among low-income small store customers. METHODS/DESIGN: BHRR is 2x2 factorial design randomized controlled trial. Fifteen regular customers recruited from each of 24 participating corner stores in Baltimore City were enrolled. Food stores were randomized to 1) pricing intervention, 2) communications intervention, 3) combined intervention, or 4) control. Pricing stores were given a 10-30% price discount on selected healthier food items, such as fresh fruits, frozen vegetables, and baked chips, at the point of purchase from two food wholesale stores during the 6-month trial. Storeowners agreed to pass on the discount to the consumer to increase demand for healthy food. Communications stores received visual and interactive materials to promote healthy items, including signage, taste tests, and refrigerators. Primary outcome measures include consumer food purchasing and associated psychosocial variables. Secondary outcome measures include consumer food consumption, store sales, and associated storeowner psychosocial factors. Process evaluation was monitored throughout the trial at wholesaler, small store, and consumer levels. DISCUSSION: This is the first study to test the impact of performance-based pricing and communications incentives in small food stores, an innovative strategy to encourage local wholesalers and storeowners to share responsibility in creating a healthier food supply by stocking, promoting, and reducing costs of healthier foods in their stores. Local food wholesalers were involved in a top-down, participatory approach to develop and implement an effective and sustainable program. This study will provide evidence on the effectiveness of price incentives and health communications, separately and combined, among a low-income urban U.S. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02279849 (2/18/2014).

Relation between the Supplemental Nutritional Assistance Program cycle and dietary quality in low-income African Americans in Baltimore, Maryland.

BACKGROUND: There has been limited research regarding the Supplemental Nutritional Assistance Program (SNAP) and recipients' dietary quality during the days and weeks after benefit disbursement. OBJECTIVE: We examined the relation between participants' stages in the SNAP cycle and their macronutrient consumption, Healthy Eating Index (HEI) scores, and fruit and vegetable intake. DESIGN: In this cross-sectional study, we analyzed single 24-h dietary recalls collected from 244 African American SNAP participants recruited near 24 corner stores in Baltimore City. A multiple linear regression analysis and bootstrapping were used. RESULTS: Among participants who received a SNAP benefit ≤15 d before being surveyed, energy intake adjusted for minimum energy requirements (-4.49%; 95% CI: -8.77%, -0.15%) and HEI dairy scores (-0.12; 95% CI: -0.22, -0.01) were lower for each 1-d increase in the time since SNAP distribution (TSSD). Among participants who received SNAP benefits >15 d before being surveyed, energy intake (1.35%; 95% CI: 0.01%, 2.73%), energy intake adjusted for minimum energy requirements (3.86%; 95% CI: 0.06%, 7.96%), total fat intake (1.96%; 95% CI: 0.29%, 3.8%), saturated fat intake (2.02%; 95% CI: 0.23%, 4.01%), and protein intake (2.09%; 95% CI: 0.70%, 3.62%) were higher per each 1-d increase in the TSSD. CONCLUSIONS: These findings suggest that the relation between the TSSD and macronutrient intake might be U-shaped, with higher intake of calories, fat, and protein in individuals in the very early and late stages of their SNAP cycles. Foods high in these nutrients might be cheaper, more accessible, and have a longer shelf-life than healthier options, such as fruit, vegetables, and whole grains, for SNAP participants when their benefits run out. Additional efforts are needed to investigate the effect of the TSSD on dietary intake by using a longitudinal design and to improve the quality of dietary intake in African American SNAP participants.

Assessing dietary intake among infants and toddlers 0-24 months of age in Baltimore, Maryland, USA.

OBJECTIVE: To characterize food and nutrient intake and develop a population-specific food list to be used as a comprehensive dietary assessment tool for Baltimore infants and toddlers aged 0-24 months. The data were used to inform the Growing Leaps and Bounds (GLB) program, which promotes early obesity prevention among Baltimore infants and toddlers. RESEARCH METHODS & PROCEDURES: A cross-sectional dietary survey using 24-hour recalls among randomly selected primary caregivers of infants and toddlers was conducted. RESULTS: Data were collected from 84 children, (response rate 61%) 45 boys; 39 girls. Mean daily energy intakes were 677 kcal, 988 kcal, and 1,123 kcal for children 0-6 months, 7-12 months and 13-24 months, respectively. Infants 0-6 months had higher percentage of energy from fat (48%) than infants 7-12 months (34%) and 13-24 months (31%). Mean daily intakes for all nutrients among 0-12 months old were ≥ Dietary Reference Intakes (DRI), while toddlers 13-24 months had inadequate vitamins A, D, and E intake. Breastfeeding occurred in 33% of infants and toddlers 0 to 6 months, while less than 3% of those aged 7 to 24 months were breastfed. A 104-item food list with eight food and drink categories was developed. CONCLUSIONS: Infants were formula fed with a higher frequency than they were breastfed. The consumption of high-sugar and high-fat foods (e.g. sweetened drinks, French fries) increased with each age group, which can increase the risk of childhood obesity.